Thursday, November 29, 2007

One of the most basic principles I was taught as a tobacco control practitioner was that there is no merit to anything that the tobacco companies or their allies say. By the simple virtue of any statement having been made by a tobacco company or tobacco ally, it was automatically invalid. In contrast, I was taught that virtually any statement made by a tobacco control group had merit.

In a showdown between conflicting statements between a tobacco company and a tobacco control group, it was unfathomable that the tobacco company could be correct. One did not even need to examine or analyze the statement at issue. Simply knowing the source of the two statements was enough to cast judgment. The tobacco control group’s statement was correct.

For many years, I believed this to be the case and I operated under this assumption. However, I have come to realize that it is no longer the case. The scientific integrity of the tobacco control movement has deteriorated to such a degree that one can no longer evaluate claims solely on the basis of whether they are made by a tobacco control group versus a tobacco company or tobacco ally. I’m not sure that was ever the case, but in this post, I will discuss the current state of affairs, not the past.

The Rest of the Story

Perhaps the most astounding example of the lack of credibility within tobacco control in 2007 is the Office of the Surgeon General itself.

When I worked at CDC in the Office on Smoking and Health between 1993 and 1995 and helped write and edit several of the Surgeon General’s reports, I had the highest degree of respect and admiration for the Surgeon General’s office and its scientific standards of excellence. The scientific review of the Surgeon General’s report and every statement made by the Surgeon General was meticulous. Every statement made was subjected to layer after layer of scientific review. We would analyze every word in the statement to make sure that it could not be misconstrued. There was a general feeling that the conclusions of the Surgeon General had to be completely beyond reproach.

Often, there were conclusions that I felt would be perfectly sound for the Surgeon General to make. However, because of slight hesitation on the part of some scientists, and out of fear that the tobacco industry might challenge these statements, we did not offer to the Surgeon General any statement that could not be easily and definitively defended. Even if the majority of scientific groups that had reviewed a particular health effect of smoking or secondhand smoke had concluded that the evidence for that effect was sufficient, we would hold out for the few remaining groups before putting that conclusion into the voice of the Surgeon General. The voice of the Surgeon General meant that the science was beyond reproach. The conclusion was extensively reviewed and meticulously well-documented.

Now in 2006, as I showed yesterday, the Surgeon General came in front of the American people and told them that just a brief exposure to secondhand smoke was enough to cause heart disease and lung cancer. The Surgeon General concluded that a brief exposure to secondhand smoke may have life-threatening cardiovascular and carcinogenic effects.

In contrast to the Surgeon General’s office that I once knew, this time there was not only absence of meticulous documentation for the statement, but there was the absence of any scientific evidence to support it. There are no studies (count them: zero point zero) which demonstrate that a brief exposure to secondhand smoke poses a risk of lung cancer. There are no studies which demonstrate that a brief exposure to secondhand smoke can cause hardening of the arteries (atherosclerosis). Yet this is precisely what the Surgeon General concluded in front of the television cameras for all to hear and read about. These conclusions remain online today, for all to continue to read.

Another example is a recent report by the Harvard School of Public Health on changes in nicotine yields of cigarettes over the past nine years. According to the report, cigarette companies - including Philip Morris - steadily increased the nicotine yield of their cigarettes - including Marlboro - during the period 1997-2005. The report describes the increase as being a total of 11% over the seven-year period 1998-2005, or an average increase of 1.6% each year during that period.

According to the report, Marlboro brands "showed a significant increase in smoke nicotine yield." During the overall study period of 1997-2005, the report estimates the increase to be 0.019 mg per year. The report concludes that there has been a "statistically significant trend in increased smoke nicotine yield of 0.019 mg per cigarette (1.1%) per year from 1997-2005 as measured by a smoking machine under the MA method." This trend was said to hold for all market categories, and in particular, for the most popular cigarette brand - Marlboro: "The present analysis of the leading U.S. brand family, Marlboro, demonstrates a significant increase in smoke nicotine yield, contradicting the PM USA claims."

Philip Morris took issue with the study's conclusions, arguing that there was no increase in the nicotine yield of Marlboro cigarettes between 1997 and 2006 and that there are no consistent trends indicating an increase in these yields over time, although there are random fluctuations over the time period.

Using the data on nicotine yields of Marlboro cigarettes provided by Philip Morris to the Massachusetts Department of Public Health (MDPH) for the years 1997 through 2006, I conducted my own analysis of the trends in Marlboro nicotine yields. I found that the average nicotine yield of all 16 Marlboro sub-brands in 1997 was 1.81 mg, and the average nicotine yield of all 16 Marlboro sub-brands in 2006 was 1.81 mg. In other words, there was no change in the average nicotine yield of Marlboro cigarettes from 1997 to 2006.

In this particular case, Philip Morris was right and the report by anti-smoking researchers was wrong.

Another example is the decision by the Department of Justice to alter a proposed smoking cessation remedy in the RICO lawsuit from a $130 billion program to a $10 billion program. Anti-smoking groups widely attacked Associate Attorney General Robert McCallum and accused him of ethical wrongdoing. They also attacked the Bush administration for political interference in changing the nature of the proposed remedy and weakening the case.

The truth, however, was that the change in remedy did not weaken the case (if anything, it strengthened it). The initial remedy would never have passed muster with the D.C. Court of Appeals because it was not consistent with the Court's interpretation of the RICO civil remedies provisions. As it turns out, even the altered remedy did not pass muster with Judge Kessler herself.

Most recently – yesterday in fact – tobacco companies and anti-smoking groups came head-to-head over whether R.J. Reynolds’ decision to discontinue cigarette advertising in magazines in 2008 was a political response to the Campaign for Tobacco-Free Kids’ complaint about its Camel insert in Rolling Stone magazine (as claimed by the Campaign for Tobacco-Free Kids) or whether it was a business decision made prior to that revelation (as claimed by R.J. Reynolds).

If this were 1995, I would have without hesitation put my faith in the Campaign for Tobacco-Free Kids and believed that R.J. Reynolds was lying to the public. Today, however, I find myself leaning toward the R.J. Reynolds side of these conflicting views of what occurred.

The rest of the story is that it is no longer the case that you can simply trust the anti-smoking groups as being credible sources of information and discount opposing tobacco industry or tobacco industry ally accounts of the same information.

This is precisely why I have been so outspoken in challenging anti-smoking groups to remain accountable for their public statements. The days of anti-smoking groups having credibility and tobacco companies and their allies being automatically untrustworthy appear to be over. Now, you have to be skeptical of everything you hear, no matter what the source.

In fact, this is part of the reason why The Rest of the Story exists. There needs to be some source for at least a somewhat balanced and at least partially open and broad perspective on tobacco control news, policies, and issues.

Here is a complete list with links to all of my previous Challenging Dogma posts in this series:

Wednesday, November 28, 2007

According to an editorial published last week in the Wichita Eagle, the United States Surgeon General has concluded that even brief exposure to secondhand smoke can cause heart disease and lung cancer in nonsmokers.

The editorial states: "A landmark U.S. surgeon general's report in 2006 found that there is no risk-free level of exposure to secondhand smoke and that even brief exposure to tobacco smoke could cause heart disease and lung cancer in nonsmokers."

This means that if a nonsmoker is exposed even briefly to secondhand smoke, he or she is at increased risk of developing heart disease and lung cancer. Walk into a smoky bar for 30 minutes and you could walk away with more than a light buzz - you could walk away with heart disease and lung cancer, according to the Surgeon General as cited in the Wichita Eagle.

For the record, the 2006 Surgeon General's report states nothing of the sort. Nowhere does it conclude that brief exposure to secondhand smoke is sufficient to cause heart disease and/or lung cancer in nonsmokers. What the report concludes is that chronic exposure to secondhand smoke can cause heart disease and lung cancer in nonsmokers.

However, in his public relations materials (i.e., propaganda) surrounding the release of the report, the Surgeon General did indeed state that brief exposure to secondhand smoke can cause heart disease and lung cancer in nonsmokers.

Here is what the Surgeon General's report concluded regarding the effects of secondhand smoke exposure on heart disease and lung cancer:

"The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and lung cancer among lifetime nonsmokers. ... The pooled evidence indicates a 20 to 30 percent increase in the risk of lung cancer from secondhand smoke exposure associated with living with a smoker. ... The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and increased risks of coronary heart disease morbidity and mortality among both men and women."

"Even brief exposure to secondhand smoke has immediate adverse effects on the cardiovascular system and increases risk for heart disease and lung cancer, the report says."

And here is what the Surgeon General stated in his remarks to the media:

"Breathing secondhand smoke for even a short time can damage cells and set the cancer process in motion. Brief exposure can have immediate harmful effects on blood and blood vessels, potentially increasing the risk of a heart attack."

Here is what the Surgeon General stated in an accompanying fact sheet:

"Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system, interfering with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of heart attack."

And here is what the Surgeon General says in an accompanying brochure:

"Even a short time in a smoky room causes your blood platelets to stick together. Secondhand smoke also damages the lining of your blood vessels. In your heart, these bad changes can cause a deadly heart attack."

The Rest of the Story

To try to piece together what is going on here for you, these are the facts as I see them:

1. The Surgeon General's report concluded (correctly, in my opinion) that chronic exposure to secondhand smoke produces a small elevation in risk (relative risk of approximately 1.3 for spouses of smokers) for heart disease and lung cancer among nonsmokers.

2. The Surgeon General completely misrepresented the conclusions of his own report in disseminating his public relations materials surrounding the release of the report. While his report documented an increased risk of heart disease and lung cancer associated with chronic secondhand smoke exposure, it provided no evidence of an increased risk of the development of heart disease or lung cancer associated with brief exposure to secondhand smoke. Yet the Surgeon General clearly claimed that brief exposure does cause such an increased risk of both heart disease and lung cancer.

3. The Wichita Eagle has completely distorted the science regarding the acute cardiovascular effects of secondhand smoke. Their claims about the effects of brief exposure to secondhand smoke are not only wrong, but scientifically implausible, and absurd.

4. However, it appears that the Wichita Eagle is not solely or perhaps at all responsible for this scientific error. Instead, it appears that the Eagle was simply quoting what the Surgeon General stated in his press release.

The rest of the story, then, is that the Surgeon General's misrepresentation of the scientific evidence regarding secondhand smoke in his own report has led to a gross distortion of the science to the public. This has occurred almost a year and a half following the release of the initial report. And it is likely to continue to occur.

It appears that the Surgeon General's deceptive and arguably inaccurate propaganda regarding the effects of brief secondhand smoke exposure, which conflicted with the conclusions in his own report, continue to result in a public misperception of the health risks of secondhand smoke exposure.

In many ways, I don't blame newspapers for this. When the Surgeon General makes a statement, it seems reasonable (or used to at least) to believe that what he says is reasonably accurate.

The blame seems to lie with the Surgeon General himself, and/or with the Surgeon General's office or associated offices that prepared the ancillary materials that accompanied the actual report.

I think there is only one way to fix the damage that has been done and to prevent further damage, and that is for the Centers for Disease Control and Prevention (CDC) to clarify (i.e., correct) the Surgeon General's statement. I think CDC has a responsibility to the public to do this.

I don't see how CDC can continue to remain silent in the face of this kind of distortion of the science regarding the dangers of secondhand smoke.

While I certainly hope that Wichita will enact a strong workplace smoking ban that includes all restaurants and bars, I hope that they don't enact it based on the mistaken belief that brief exposure to secondhand smoke is causing heart disease and lung cancer among Wichitans. The evidence that chronic exposure to secondhand smoke causes these diseases is sufficient to justify protecting all Wichita workers from the hazards of tobacco smoke exposure.

We don't need the Surgeon General's distortion of the truth to help support smoking bans. In fact, the deception only hurts the anti-smoking cause. It makes those of us who support smoking bans look like liars and it casts all of what we say - even our conclusions about the effects of chronic exposure - into public doubt.

Tuesday, November 27, 2007

My interview with EudoxaScience, which appears today, can be found here. I thought that EudoxaScience asked some intriguing questions about the current state of tobacco control and what the future holds.

According to Smokefree Pennsylvania, if you frequently take your kids out to restaurants, you may be a child abuser. If those restaurants allow smoking, then according to Smokefree Pennsylvania, you are indeed a child abuser.

This means that if you repeatedly take a child to a restaurant that allows smoking (thus exposing your child to hazardous tobacco smoke pollution), you are a child abuser.

It also means that if you take your child over to a friend's house and that friend smokes, you are abusing your child.

Or that if your Uncle Henry is a smoker and you don't kick him out of the house when he wants to light up at family get-togethers because you don't want to hurt his feelings, you are abusing your child if these family functions are repeated.

It also means that if you do not believe that secondhand smoke is harmful and you smoke in the presence of your child without any intent to harm the child, you are a child abuser.

And it means that if you are not aware that secondhand smoke is harmful to your child, you are a child abuser if you smoke around the child, even though you had no knowledge that your smoke was harming the child.

And it also means that if there is no evidence that secondhand smoke exposure is causing any health problems for your children (they are not getting ear or respiratory infections or developing asthma because of it), you are still abusing your children if you repeatedly smoke around them.

It means that if you take your kid to New England Patriots games and you visit the concession stands, you are a child abuser (since it is almost impossible to avoid smoke exposure at Pats games if you visit the concession stands).

The Rest of the Story

I view this as a very important story because it demonstrates the current mentality of the anti-smoking movement. It is truly a crusade. It is a narrow-minded movement with blinders on that is unable to see any values beyond not smoking. It is a movement for which not smoking has moral, and not just health value. Most importantly, it is a movement that has been overtaken by fanaticism, by which I mean zeal unchecked by reason.

After all, reason would tell you that exposing a child to secondhand smoke is not, in and of itself, a form of child abuse. Only overzealous thinking that is unchecked by reason would lead one to a conclusion that virtually every parent in the 1980s and earlier was a child abuser (since exposure of children to secondhand smoke in that era was virtually ubiquitous).

It is this lack of reasoning that precludes me from considering myself a part of the current anti-smoking movement. As a scientist and a trained policy analyst, I just cannot divorce myself from reason, argumentation, and development of solid foundations, bases, and justifications for policy positions.

The end result of the abandonment of reason is not only an incorrect and absurd definition of child abuse. It is also what amounts to an offensive and insensitive statement that could well offend anyone who actually has been a victim of child abuse or anyone who knows and loves someone who has been such a victim.

An op-ed column by social commentator Rita Panahi published on November 6 in the Herald-Sun (Australia's leading daily newspaper) argues that smokers - like criminals, junkies, the violent, and the insane - should not have children. She equates smoking around children to child abuse and calls for laws that would prohibit smoking during pregnancy. She also calls for legislation that would mandate cotinine testing of pregnant women and deny government benefits to those found to have smoked during pregnancy.

Panahi writes: "Let's be honest, some people just shouldn't have kids. Criminals, junkies, the violent, the insane and smokers. Yes, smokers. They are a hazard not only to themselves but to the poor kids who are unfortunate enough to have them as parents. If an adult with the full knowledge of the dangers of smoking chooses to inhale cancer causing toxins then that's their business but they have no right to expose unwilling children to their filthy habit. Certainly, a woman who smokes while pregnant is not worthy of having children let alone receiving a generous government grant for every nicotine-addicted baby she brings in to this world." ..."It's easy to make a case against violent, unstable types having kids, yet latest research shows that smokers also pose an imminent danger to their offspring... ." ..."If that fact alone isn't enough to persuade selfish mums-to-be to butt out their final cigarette, then nothing will, short of legislation banning them from using nicotine-based products. Such a ban would be difficult to enforce but the clear message it sends - that smoking while pregnant is tantamount to child abuse - would hopefully shame a few more women into give up their nicotine habit." ...

"Laws banning pregnant women from buying and using cigarettes would have an immediate impact. A further measure can be the linking of the baby bonus to mothers remaining smoke-free for the term of their pregnancy, a simple test for nicotine can be conducted at the same time other routine blood work is completed during pregnancy."

The Rest of the Story

This column should summon the warning bell for all tobacco control groups. It should alert these groups that the anti-smoking crusade is pushing people too far and that if unrestrained, it will lead to the abuse of personal freedoms, rights, privacy, and autonomy.

If anti-smoking groups were communicating their messages effectively (or perhaps I should say: if anti-smoking groups were communicating the most appropriate messages), then I truly don't believe that a prominent newspaper like the Herald-Sun would be running a column like this without editing it for such offensive material.

And offensive it is.

To equate smokers with criminals, junkies, the violent, and the insane? Excuse me? What the hell are you talking about?

Should fat people also not have children? How about those with diabetes? How about those who eat crappy, fatty food?

How about if Rita Panahi just gives us a list of all the parental health behaviors that have been shown to affect the health of children, and we ban all of them, instituting a system of mandatory intrusive testing for these behaviors in order for women to be eligible for government benefits?

And to outlaw the purchase of cigarettes by women who are pregnant? What are we going to do? Set up a pregnancy testing station at every place where cigarettes are sold? And what if a pregnant women does smoke? What do we do then? Lock her up in jail? Apparently not. But we will, according to Panahi, take away her government benefits. How healthy can that be for the child? To deny them of food? Such a policy would be particularly devastating for the poor -- those who could least afford being stripped of their only means of providing nutrition to their infants and children. This is a real child-loving policy if I've ever heard of one.

Anti-smoking groups should be fighting over the opportunity to be the first to condemn this column. So far, I haven't seen any outcry about it from within the tobacco control community.

And that's precisely the problem. Because if anti-smoking groups were to condemn this kind of offensive speech, it would put an end to it - at least in the mainstream media. It is the fact that anti-smoking groups remain silent that keeps these kind of attitudes alive. Some anti-smoking groups have even been supporting ideas not too far off from those espoused here.

For the movement to remain viable, groups need to be able to take positions that are in opposition to those of other anti-smoking groups. Unfortunately, as I've learned (as recently as last week), you cannot criticize any statement or established position of an organization within the movement, and expect to stay within the movement yourself.

I'm therefore not holding my breath waiting for an anti-smoking organization to come along and condemn this column and the attitudes that underlie it.

Sunday, November 25, 2007

BBC Radio's Leading Edgeprogram from Thursday, November 22 featured a column in which I discuss the widespread misrepresentation by anti-smoking groups of the science regarding the acute cardiovascular effects of secondhand smoke and the implications of this deceptive communication to the public.

My segment begins around the 19:15 mark. After this week is over, you can access the column by clicking on the appropriate date (November 15) under Previous Programmes.

Wednesday, November 21, 2007

In an article in the Indianapolis Star, an Indiana University anti-smoking researcher is quoted as saying that active and passive smoking can kill a person immediately from heart disease, without requiring years of exposure. The comment came in the context of defending the plausibility of results of a study which purported to show a 70% decline in heart attacks in nonsmokers immediately following the implementation of a smoking ban in Monroe County, Indiana. I have previously explained why the conclusions of that study are invalid (post #1; post #2).

According to the article: "When substances in smoke enter the bloodstream, they can throw off the delicate balance of chemistry in the small blood vessels, said Dr. Stephen J. Jay, a professor of medicine and public health at the Indiana University School of Medicine. That can cause a person's platelets to grow sticky and clump together, creating a blockage that can result in a heart attack or stroke. 'This is surprising to a lot of people who generally think that smoking is something that causes disease 30 or 40 years down the pike,' Jay said. 'What people don't understand is that if you look at active smoking as well as passive smoking in population studies, you can see that exposure to smoke, active or passive, is perfectly capable of killing you now.'"

The Rest of the Story

While I understand that the Indiana study is quite weak, is based on extremely small numbers of heart attack patients, and draws a conclusion that is quite implausible, I don't see how it helps the situation to defend the study's conclusion by misleading the public into believing that it does not take years of smoking to kill you.

The truth is that we do not see people dying of heart attacks in their 20's or even 30's from smoking (except in rare, exceptional situations). Clearly, it takes at least 15 to 20 years of smoking before you develop heart disease severe enough to cause a heart attack. So I'm not sure what the point is of telling the public that smoking can kill you right away.

It is highly misleading to tell the public that smoke exposure can cause a blockage that can result in a heart attack or stroke without clarifying that the person must have pre-existing coronary artery or cerebrovascular disease in order for this to occur. A healthy person is not going to have a heart attack or stroke because they are exposed briefly to tobacco smoke.

It seems to me that these absurd statements are a desperation attempt to defend a study whose conclusions we all realize are completely implausible. In fact, it would take quite absurd assumptions for the conclusions of the Indiana study to be correct. The only way we can successfully defend the plausibility of those findings is if we convince the public that healthy people do indeed drop dead instantly from brief exposure to secondhand smoke.

Even Dr. Stan Glantz himself admits that brief exposure to secondhand smoke is not going to cause a heart attack in a person who is healthy (who does not have existing coronary artery disease).

In the long run, the tobacco control movement is only going to be hurt by these absurd exaggerations. If the movement loses its scientific credibility, it can no longer be effective. And statements like this are not going to help maintain the scientific credibility of the movement.

Tuesday, November 20, 2007

According to a study published this month in the Journal of Drug Education, the smoking ban enacted in Monroe County, Indiana in August 2003 has led to a 70% decline in heart attacks among nonsmokers with no previous history of cardiac disease (see: Seo D-C, Torabi MR. Reduced admissions for acute myocardial infarction associated with a public smoking ban: Matched controlled study. Journal of Drug Education 2007; 37:217-226).

As I explained yesterday, the study compared the number of heart attacks among patients without prior cardiac disease or major cardiac risk factors in Monroe County with the number of heart attacks among similar patients in Delaware County, a county in Indiana with similar demographics but no smoking ban. The data were compared for a 22 month period prior to the ban (August 2001 through May 2003) and a 22 month period following the ban (August 2003 through May 2005). The smoking ban was implemented in August 2003 and included all workplaces and restaurants. Bars were initially exempt, but became smoke-free in January 2005. Analysis was stratified by smoking status of the heart attack patients.

The paper reports a 70% decline in heart attacks among nonsmoking patients in Monroe County, compared to only an 11% decline in heart attacks among nonsmoking patients in Delaware County. There was no significant change in heart attacks among smoking patients in either county.

The authors conclude that the substantial reduction in observed heart attacks in Monroe County was attributable to the smoking ban.

If you examine the details from the paper, it turns out that the total number of nonsmoking heart attack patients upon which the study conclusions are drawn is 22 in Monroe County and 34 in Delaware County. That is, the number of heart attacks in Monroe County decreased from 17 to 5, and in Delaware County decreased from 18 to 16.

The paper reports the decline in heart attacks in Monroe County to be -12, with a 95% confidence interval of -21.19 to -2.81. This means the decline is statistically significant. One can conclude that the true number of heart attacks in Monroe County definitely went down, not up.

The paper reports the decline in heart attacks in Delaware County to be -2, with a 95% confidence interval of -13.43 to +9.43. This means the decline is not statistically significant. The confidence interval crosses zero, which means that the true number of heart attacks in Delaware County could have gone down or it could have gone up.

Based on the finding that the decline in heart attacks in Monroe County was statistically significant and the decline in Delaware County was not statistically significant, the paper concludes that there was a significant difference in the decline in heart attacks between the two counties.

The Rest of the Story

Unfortunately, the paper relies on the wrong analysis to analyze these data. The mere fact that the decline in heart attacks in Monroe County was statistically significant and the decline in heart attacks in Delaware County was not statistically significant does not mean that the degree of change in heart attacks between the two counties was statistically different. That is the wrong statistical analysis to apply to these data to answer the primary research question at hand.

The primary research question at hand is whether or not the change in heart attacks in Monroe County was statistically different from the change in heart attacks in Delaware County. To test that, one needs to do 2 things:

(1) generate an estimate of the difference in the change in heart attacks between the two counties; and

(2) generate an estimate of the degree of uncertainty (the "standard error") in that estimate of the difference in the change in heart attacks between the two counties.

Unfortunately, the paper only does the first of these. It does not do the second.

The paper provides an estimate that the difference between the change in heart attacks in Monroe County and Delaware County was -10. That is, the paper estimates that the decline in heart attacks in Monroe County was 10 greater than the decline in heart attacks in Delaware County (or to be more accurate, that the change in heart attacks in Monroe County was 10 more negative than the change in Delaware County - it could have been that the true number of heart attacks in Delaware County actually went up).

However, the paper does not provide a confidence interval around this estimate of -10. It does not provide the reader of an idea how much variability there is around this estimate. With 95% certainty, can we be sure that this estimate of -10 is not actually greater than -20? Or, can we be sure with 95% certainty that this estimate is not actually positive (greater than zero). We need to know whether the confidence interval includes zero or not. If it does, then the estimate is not statistically significant.

Because the paper does not provide this estimate of the confidence interval around the estimate of a -10 difference in the change in heart attacks between the two counties, we are unable to conclude (and the paper is unable to conclude, despite its conclusion) that there was a significant difference in the change in heart attacks between the two counties, with Monroe County experiencing a greater drop in heart attacks.

We can, however, make a rough estimate of the likely 95% confidence interval around the estimate of -10 by calculating the variance of the estimates for the change in heart attacks in each county, since those confidence intervals are provided. If one does this, one finds that the likely 95% confidence interval around the -10 actually includes zero. In fact, the upper limit of the confidence interval appears to reach as high as +4.7.

In other words, the study findings are entirely consistent with the possibility that the change in heart attacks in Monroe County was actually 4.7 lower than the change in Delaware County. It is entirely consistent with the results of the paper that the heart attacks in Delaware County dropped by more than the heart attacks in Monroe County.

For example, it is entirely possible that the true number of heart attacks in Monroe County fell by 3 (which is within the 95% confidence interval for the change in heart attacks in Monroe County) and that the true number of heart attacks in Delaware County fell by 8 (which is well within the 95% confidence interval for the change in heart attacks in Delaware County).

This means that the study cannot conclude that the true number of heart attacks in Monroe County did not decline by more than the true number of heart attacks in Delaware County.

The rest of the story, then, is that based on the very data presented in the paper, it is entirely possible that the smoking ban was associated with a lowering of the decline in heart attacks in Monroe County.

Why is the confidence interval around the estimate of -10 so wide that it includes zero? The reason is that the number of heart attacks in the study is so very small.

Even though the number of heart attacks in Delaware County seemed to stay about the same (18 and then 16), the numbers are so small that the paper can not rule out that the true number of heart attacks might actually have gone down by as much as 13, or up by as much as 9.

In other words, there is so much uncertainty about whether heart attacks in Delaware County went up, down, or stayed the same, that it becomes impossible to conclude that the difference of 10 in the change in heart attacks between the two counties was statistically significant.

I hope I explained that well enough. I tried to make it as clear as possible, but if I need to clarify some of this in the comments, I'll be happy to do that.

The bottom line is that the paper presents the wrong statistical analysis. Based on the data presented in the paper, the conclusion that the number of heart attacks among nonsmokers in Monroe County declined by more than the number of heart attacks in Delaware County is not supported, and therefore is invalid.

It is difficult for me to imagine that none of the reviewers caught this and asked the authors to present such an estimate of variability around this key statistic, but it happened. Sometimes these errors, even when there are sentinel errors like this one, can fall through the cracks.

By the way, I'm not arguing that the smoking ban failed to reduce the number of heart attacks in Monroe County. I'm simply arguing that this particular paper provides essentially no basis for drawing such a conclusion.

Legislators will soon be considering legislation that would eliminate smoking in workplaces, including bars, restaurants, and casinos in Indiana. While I strongly support this legislation to protect the health of nonsmokers, I would hope that anti-smoking advocacy groups in Indiana will not rely on this particular study to back up their support for this bill. I think that health advocates actually hurt their cause more than help it when they rely on junk science like this to promote public policy.

According to a study published this month in the Journal of Drug Education, the smoking ban enacted in Monroe County, Indiana in August 2003 has led to a 70% decline in heart attacks among nonsmokers with no previous history of cardiac disease (see: Seo D-C, Torabi MR. Reduced admissions for acute myocardial infarction associated with a public smoking ban: Matched controlled study. Journal of Drug Education 2007; 37:217-226).

The study compared the number of heart attacks among patients without prior cardiac disease or major cardiac risk factors in Monroe County with the number of heart attacks among similar patients in Delaware County, a county in Indiana with similar demographics but no smoking ban. The data were compared for a 22 month period prior to the ban (August 2001 through May 2003) and a 22 month period following the ban (August 2003 through May 2005). The smoking ban was implemented in August 2003 and included all workplaces and restaurants. Bars were initially exempt, but became smoke-free in January 2005. Analysis was stratified by smoking status of the heart attack patients.

The paper reports a 70% decline in heart attacks among nonsmoking patients in Monroe County, compared to only an 11% decline in heart attacks among nonsmoking patients in Delaware County. There was no significant change in heart attacks among smoking patients in either county.

The authors conclude that the substantial reduction in observed heart attacks in Monroe County was attributable to the smoking ban.

In a press release issued by Indiana University to accompany the publication of the study, the authors claim that: "Exposure to second-hand smoke for just 30 minutes can rapidly increase a person's risk for heart attack, even if they have no risk factors. The smoke, which contains carbon monoxide, causes blood vessels to constrict and reduces the amount of oxygen that can be transported in the blood."

The Rest of the Story

To be blunt, this study is crappy and its conclusions are completely invalid. This study would never have passed scrutiny with me had I been asked to review it.

In fact, the results of the study fail to support the paper's conclusion.

While the press release sounds quite impressive, if you take the time to read the actual study, you'll find that the sweeping conclusion that a smoking ban reduced heart attacks among nonsmokers by 70% is based on a total of only 22 heart attacks. That's right. There were only 22 heart attacks among nonsmoking patients in Monroe County in this study between August 2001 and May 2005. And there were only 15 heart attacks among smoking patients in Monroe county during the study period.

The sample size of the study is so small that it is ridiculous to conclude that the observed decline from 17 heart attacks (2001-2003) to 5 heart attacks (2003-2005) was attributable to the smoking ban. With sample sizes this small, the variation in the number of annual heart attacks is expected to be enormous. There is no way that the study can determine that the observed decline was due to the smoking ban, rather than simply to random variation in the number of heart attacks in this small geographic area (only one hospital was included in the study).

More importantly perhaps, if you look at the results, you'll see that there is no significant difference between the change in heart attacks in Monroe versus Delaware counties over the study period. The confidence intervals around the estimates of the change in heart attacks in the two counties overlap widely. Based on the reported confidence intervals, the decline in heart attacks in Monroe County could be as low as 3, and the decline in heart attacks in Delaware County could be as high as 13. In other words, it is entirely plausible, based on the study findings, that the decline in heart attacks in Delaware County was greater than that in Monroe County.

These results make it clear that there is no significant difference in the change in heart attacks between the two counties over the study period, thus nullifying the study conclusion.

I honestly have no idea how something like this managed to get through the peer review process and into publication. But it really doesn't matter. The point is -- the study clearly does not provide support for the conclusion that the smoking ban in Delaware County resulted in a 70% decline in heart attacks among nonsmokers.

There are two other severe problems with the study which deserve mention (as if the above weren't enough).

First, only one hospital was included in the study. It was assumed that all heart attacks suffered by patients living in Monroe County would be picked up at Bloomington Hospital. This is not a fair assumption, however. People travel and if a heart attack occurred while traveling, a person would not present at Bloomington Hospital. Normally, this would not be a problem. But with so small a number of total heart attacks, even if one or two people had heart attacks while away from Bloomington, this would render the study results invalid.

Second, the study excluded patients with a prior history of cardiac disease and those with risk factors for heart disease (such as high cholesterol and hypertension). However, these would be the precise patients among whom a decline in heart attacks attributable to a smoking ban might be expected. This exclusion makes no sense.

The rest of the story is that this study is another example of the junk science that passes muster these days in tobacco control research. It seems that studies which report a decline in heart attacks associated with smoking bans have an automatic green light, regardless of their scientific merit.

But the most unfortunate part of this story is that the press release contains the same fallacious statement that is being made by more than 100 anti-smoking groups. Without any evidence to support it, the press release claims that 30 minutes of secondhand smoke exposure rapidly increases a person's risk of a heart attack even if that person is otherwise healthy (they have no risk factors for heart disease). In fact, the press release offers an explanation for the increased risk -- as if it has already been proven to be the case. The explanation is that the carbon monoxide causes blood vessels to constrict and reduces the amount of oxygen that can be transported in the blood.

Well the truth is that hypoxia (reduced oxygen delivery) alone is not a cause of most heart attacks. You need to have restricted blood flow through the coronary arteries.

More importantly, the truth is that 30 minutes of secondhand smoke has been demonstrated not to cause constriction of the blood vessels supplying blood to the heart. Coronary blood flow was not decreased in subjects who were exposed to secondhand smoke for 30 minutes (see: Otsuka R, Watanabe H, Hirata K, et al. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001; 286:436-441).

The press release basically seems to be making this all up as it goes along, all in an apparent effort to support findings that are neither valid nor plausible.

This is important because it demonstrates that outside of the tobacco control movement, scientists take a look at the claims being made by these anti-smoking groups and immediately see that the claims are patently false. It is only those within the anti-smoking movement who somehow have such dense blinders on that they have lost the ability to distinguish even absurd science from good science.

New data released last week by the Scottish National Health Service reveal that the national smoking ban had no detectable effect on heart attack hospital admissions, despite an earlier claim made by University of Glasgow researchers and disseminated to the media via press release that the smoking ban resulted in a startling 17% decline in heart attacks.

The data, which are reported in an article by Michael Blastland published by the BBC News, were reported by the National Health Service's Informational Services Division. They include all hospital admissions for heart attack nationwide, reported as annual standardized rates. The data show a decline of about 8% in the year following the smoking ban, which is only slightly higher than the approximate 6% decline the year preceding the smoking ban.

If one looks at the trend in heart attack rates from 1998 through 2007, one finds that based on the pre-existing trends in heart attack rates, there has been no apparent change in the rate of heart attacks following the smoking ban, which was implemented in March 2006.

These data also confirm my earlier analysis, in which I pointed out that a huge decline in heart attacks in Scotland from 1999 to 2000 occurred prior to the smoking ban and reveal the large degree of baseline variability in the data, meaning that only a junk science study would conclude that the observed decline in heart attacks during the 10 months following the smoking ban was attributable to the smoking ban. In fact, the data released last week reveal that the largest drop in heart attack admission rates occurred not following the smoking ban, but from 1999 to 2000.

Blastland writes: "It was dramatic research that made headlines everywhere. A 17% fall in the number of heart attacks in the year since Scotland stubbed out smoking in public places. Startling - if true. Few questioned the research when it was revealed two months ago. ... Then a week ago, with rather less fanfare, routine statistics on hospital activity were published by the official source for health data in Scotland, as they are every year, this time including the time since the ban. These show a fall in heart attacks for the year from March 2006 - not of 17%, but less than half as much at about 8%. ... The percentage falls in the three years before the ban were 5.1%, 4.7% and 5.7%. ... The latest release also makes clear that even an 8% fall in heart attacks is not unprecedented. There was another, larger drop between 1999 and 2000 of about 11%. This seems to demonstrate significant variability around the trend, suggesting that last year's 8% drop might even be the result of chance. It is conceivable, although perhaps unlikely, that the smoking ban had no effect at all. The figures could be a result of no more than the ordinary ups and downs of statistical variation from one year to the next."

Blastland's observations are consistent with my commentary of September 13, in which I wrote:

"To see why a thorough review of the actual study is necessary, just look at the hospital discharge data for heart attacks in Scotland. We find evidence of a large single-year decline in heart attacks of about 10% which occurred in the absence of any smoking ban. This indicates that there can be a large year-to-year variation in heart attacks in Scotland and makes it especially difficult to determine whether a 17% annual decline in heart attacks is due in part to random variation, and if so, to what extent. From the information that was provided to us, it is impossible to conclude that the smoking ban was responsible for the observed decline in heart attack admissions."

"It is also important to consider the fact that the more rapid decline in heart attack admissions in Scotland appears to have begun prior to the smoking ban. A drop in heart attack admissions of 17% (equal to what was observed after the smoking ban) actually occurred during the three-month period immediately prior to the smoking ban. It would be very questionable to attribute the observed heart attack decline to the smoking ban in the face of this evidence that heart attacks were declining substantially prior to the ban. It is entirely possible that some other factor is responsible for the observed decline."

As it turns out, it does not even appear that there has been a change in the rate of decline in heart attack admissions in Scotland. Clearly, the conclusions drawn by the researchers and disseminated to the media and the public prior to peer review of their study were premature.

The researchers who conducted the study had issued a press release on September 10, in which they highlighted the conclusion that there had been a 17% decline in heart attacks which was largely attributable to the smoking ban. The media widely disseminated this conclusion, with headlines such as: "Scottish Smoking Ban Leads to Huge Drop in Heart Attacks."

Despite issuing their press release, the researchers did not make their study available for public review and it appears that they are still not releasing it. Blastland reports that "because the data on which the StopIt study was based has never been published, and nor has the study itself, it is impossible to say exactly how it was done. Attempts to obtain it or to talk to the lead researcher have gone unanswered."

The Rest of the Story

There are two important implications of this story.

First, it demonstrates that tobacco control science is quickly deteriorating into junk science. I believe that investigator bias is becoming so strong that it is leading to completely invalid study conclusions. The Helena study conclusions, and now the conclusions from Pueblo, Piedmont, Bowling Green, Scotland, and Ireland, have all been cast into doubt. An apparently strong bias is clouding the scientific rigor of the papers being produced in this area. It represents, in my view, a true and unfortunate deterioration of the scientific integrity within the tobacco control movement.

Second, this story demonstrates the dangers of the science by press release approach which has now become the standard for these smoking ban/heart attack studies. It shows precisely why it is not prudent to issue findings that have not been validated by a peer review process. Suppose that upon peer review (or in this case, simply upon release of more complete data), it turns out that the study findings are unwarranted and invalid. Are the researchers going to then issue a press release stating that they were wrong, that their conclusion was premature and invalid, and that all news articles that the public throughout the world read to the contrary should be disregarded?

I highly doubt it. I doubt that the researchers of the Scotland heart attack study are going to pull an Emily Litella and issue a press release tomorrow saying: "Never mind."

The point is that the word is already out there. The conclusions have already been disseminated. It is too late to retract them now that they have been shown to be wrong.

This is why I view it to be inappropriate and unethical to release the results of a scientific study prior to peer review and publication. There is one exception, and that is IF (and only if) one makes the study available for public scrutiny and review. If you are going to go to the press to disseminate study findings, then you have to be willing to allow the public to see the study upon which those findings are based. Otherwise, there is no opportunity for review and scrutiny of your work.

In this case, the researchers apparently did not make their study available for public review and it appears that they still refuse to release it for public review.

The scientific standards of the tobacco control movement are rapidly crumbling. And the ethical standards don't seem to be that far behind.

Wednesday, November 14, 2007

Tuesday, I issued the following challenge to TobaccoScam (run by Dr. Stanton Glantz) and other anti-smoking advocates and organizations that have publicly defended the claim made by Action on Smoking and Health that 30 minutes of secondhand smoke exposure puts a nonsmoker at the same risk of a fatal heart attack as an active smoker:

"Either provide the evidence to back up ASH's assertion that 30 minutes of secondhand smoke exposure increases the fatal heart attack risk of nonsmokers to the same level as active smokers, or else apologize to me for having improperly suggested that I am criticizing anti-smoking organizations for no valid reason.""I am challenging TobaccoScam, as well as other advocates and anti-smoking groups which have attacked me for criticizing what I believe are highly deceptive public communications, to provide evidence of each of the following:1. Please document that the CDC has warned that 30 minutes of secondhand smoke exposure increases a nonsmoker's risk of suffering a fatal heart attack to the same level as that of active smokers.2. Please provide the scientific evidence to back up the assertion that 30 minutes of secondhand smoke exposure increases a nonsmoker's risk of suffering a fatal heart attack to the same level as that of active smokers."

As a reminder, here is ASH's statement: "Even for people without such respiratory conditions, breathing drifting tobacco smoke for even brief periods can be deadly. For example, the Centers for Disease Controls [CDC] has warned that breathing drifting tobacco smoke for as little as 30 minutes (less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker's risk of suffering a fatal heart attack to that of a smoker."

Unfortunately, I received no substantive response to this challenge. No anti-smoking advocate or group has defended ASH's claim by providing evidence either that CDC has warned that 30 minutes of secondhand smoke exposure increases a nonsmoker's risk of suffering a fatal heart attack to the same level as that of active smokers or that 30 minutes of secondhand smoke exposure increases a nonsmoker's risk of suffering a fatal heart attack to the same level as that of active smokers.

Not a shred of scientific evidence has been provided or put forward to support this scientific statement made by ASH.

In lieu of scientific evidence that I am wrong in my criticism of this statement, I did receive a number of personal attacks and insults. In other words, rather than address the scientific issue under discussion, TobaccoScam decided to instead engage in character assassination.

"I view him as a tragic figure - he has completely lost it. His view is that everybody in the tobacco control movement is corrupt and misguided except for him. You have to be careful what you say to preserve credibility in academic circles, and he is not doing that." (source)

Another very prominent anti-smoking advocate wrote: "His [Alex Beam's] embrace of Mike Siegel, unfortunately, speaks for itself." Notably, this advocate failed to even address the issue of whether the scientific argument I am making is valid or not.The Rest of the Story

The rest of the story is that the tobacco control movement seems unable to respond to arguments regarding the science of secondhand smoke in a substantive way. The only method of response known to the movement to respond to challenges to any statements being made by anti-smoking groups is to attack the scientist who stands in disagreement.

Apparently, the playbook directs anti-smoking advocates to avoid, at all cost, any substantive discussion of the science used to support the need for smoking bans. That is in the territory of gospel truth, and it cannot be challenged. If it is, the scientist who disagrees needs to be personally attacked and publicly discredited. The playbook calls for character assassination, not substantive discussion of the science. The interpretation of the science by anti-smoking groups is simply not on the table for discussion.

Let me make one thing very clear. The issue up for discussion is not whether or not I have completely lost it, partially lost it, or not lost it at all. I admit that makes for an interesting discussion, but it is in no way relevant to the issue of whether the fatal heart attack risk of a nonsmoker exposed to secondhand smoke for 30 minutes is as high as that of an active smoker. Whether I've lost it or not does not provide evidence to support such an assertion.

There are interesting arguments on both sides of the debate, by the way, over whether I've lost it or not. I certainly can provide some quite incriminating and damning evidence for the former.

But what's most fascinating to me is that so far, no one - not a single anti-smoking advocate, researcher, or group - has provided a shred of evidence that if a nonsmoker is exposed to secondhand smoke for 30 minutes, his or her risk of dying from a heart attack rises to the level of risk of a fatal heart attack for an active smoker. So far, this seems to be a one-sided debate. No evidence has been advanced to support the other side.

I think it's unfortunate that these anti-smoking groups and advocates are so baseless in their claims that they cannot summon up even a single piece of evidence to support their position, and instead, they have to attack my character.

They also have to resort to mis-stating my position. I have never argued that any anti-smoking organizations are corrupt. I've simply argued that some anti-smoking organizations are wrong in their representation of certain aspects of the science regarding the acute cardiovascular effects of secondhand smoke. I'm not alleging any corruption; I'm simply alleging that there is scientific inaccuracy. I've also never confirmed that I am not corrupt, or that I am not misguided.

I do, however, agree that if you work in tobacco control, you have to be careful what you say. Because if you say something that is in disagreement with the established wisdom of the movement, if you say something that goes against the party line, you have just thrown your tobacco control career to the wolves. It's true. You do that and you instantly lose all credibility in tobacco control academic circles (luckily, not in all other academic circles).

As my credibility within the tobacco control academic circle has decreased, my credibility within the non-tobacco control academic circle has greatly increased. It is a tradeoff that I believe is well worth making.

The response of the other prominent anti-smoking advocate who I heard from is also typical of the anti-smoking playbook: attack the person who disagrees with the party line, but by no means address the actual substance of that person's argument.

Here, the fact that Alex Beam has highlighted this story immediately discredits me, regardless of whether my argument is valid or not. I am guilty merely by association. Merely by having been quoted by Alex Beam, I am automatically discredited and ostracized from the tobacco control scientific community.

I simply don't see the damage that would be done by admitting that a statement made by a particular anti-smoking group is wrong. Look - we all make mistakes and there is no reason why ASH is not allowed to make a mistake in one of their communications. But when this happens and it is so blatant, the leaders of the anti-smoking movement have to be willing to admit that it is an error. To defend grossly misleading distortion of the science is actually worse than the original mistake.

While I understand that in the short run, it may not be advantageous to reveal the truth, in the long run it is going to destroy the tobacco control movement to risk its credibility like this. This is why I am fighting so hard for the truth. It's to preserve the movement and its effectiveness in continuing to address the leading cause of preventable death in this nation.

Today, a column by Jeff Stier in the Huffington Post blog ("Secondhand smoke exaggerations challenged") and an article by Alex Beam in the Boston Globe ("Where there's smoke...there's Dr. Siegel) highlight the misrepresentation of the science regarding the acute cardiovascular effects of secondhand smoke by anti-smoking groups.

In Jeff Stier's column at Huffington Post, he highlights the challenge that I issued yesterday to anti-smoking groups to back up the assertion - made by Action on Smoking and Health on its web site - that nonsmokers exposed to secondhand smoke for 30 minutes are at the same risk of dying from a fatal heart attack as active smokers.

As Stier summarizes it: "the evidence does not support the claim that more than 100 groups are wantonly making -- which is that acute but transient exposure increases heart-attack risk in healthy individuals. ... The "evidence" behind the ASH assertion is flimsy. Comparably-weak evidence suggesting that smoking is less dangerous than previously thought would be laughed at. To me it is obvious: some anti-smoking activists have adopted an "ends justifies the means" approach in pursuit of their noble cause."

"This is what makes Siegel's finding so troubling. We can no longer rely on the public-health establishment for scientifically accurate information. They'll fudge the numbers if they have to, so long as it promotes their overall agenda -- in this case, the drive to outlaw smoking in all public places. ... Science eventually catches up with those who hyperbolize about risks, and the public learns to disregard them. It would be tragic to see some public-health advocates lose the mantle of sound science and end up going the way of the old Tobacco Institute. Cigarette smoking is the leading cause of preventable death in the United States and needs our urgent attention. Overstating the case may help the advocates win this political battle but at significant cost to the overall public-health war."

Alex Beam writes in today's Boston Globe, after reviewing the evidence and speaking with a number of experts, including me, Dr. Stan Glantz, and folks at the Campaign for Tobacco-Free Kids, that anti-smoking groups are misrepresenting the science regarding the acute cardiovascular health effects of secondhand smoke because "the anti-smoking lobbies aren't in business to promote public health; they're in business to stay in business."

Beam writes: "Oh, my. I guess Boston University professor Dr. Michael Siegel won't be getting invited to the "right" dinner parties in towns like Newton and Brookline, where whiffs of secondhand smoke are equated with a release of Ebola virus. Siegel has just published a heretical paper in the journal Epidemiologic Perspectives & Innovations analyzing the purported effects of secondhand smoke."

Beam reports the response to this debate from two tobacco control experts: "... A spokesman for Tobacco-Free Kids declined to discussSiegel: "We don't want to say anything to categorize him in any way." "I view him as a tragic figure - he has completely lost it," says University of California tobacco researcher Stanton Glantz. "His view is that everybody in the tobacco control movement is corrupt and misguided except for him. You have to be careful what you say to preserve credibility in academic circles, and he is not doing that."

The Rest of the Story

First of all, I have to say that I am devastated that my days of partying with the 'righties' in Newton and Brookline are over. That is certainly a crushing blow from which I am not sure I can recover.

More importantly, I am glad that Dr. Glantz recognizes that I have completely lost it. I've been telling my family that for years, but no one seems to be paying any attention. Perhaps that's because they realized I had already lost it many years ago. I think it probably became apparent 38 years ago, when I frantically and desperately rooted for the Detroit Tigers in the post-Kaline era.

Dr. Glantz is wrong, however, in suggesting that I don't think of myself as being corrupt and misguided. Clearly, I must be misguided. Why else would I, in my right mind, put my entire career on the line in order to speak out for the truth? Why else would I challenge the statements that anti-smoking groups are making? This is a religious-like movement, and if you challenge the established wisdom (even if that wisdom is an errant statement made by one particular group), you have crossed the line. There is no place in this religion for you. You are a heretic. Clearly, you are misguided.

And as far as corruption goes, I have yet to publicly deny, on this blog, that I am being paid by tobacco companies to express these heretical positions. I do not here deny that I am corrupt. I just happen to believe that my interpretation of the science is correct, despite my egregious corruptness.

On a more serious note, I find it quite troubling that there is a perception that in order to remain credible in academic circles, one needs to censor what one says in order to avoid political incorrectness. This is actually the one thing Dr. Glantz said with which I agree. I think it is clear, from my experience, that one cannot challenge the established wisdom of the tobacco control movement without being ostracized from the tobacco control community. Unfortunately for Dr. Glantz and for the anti-smoking groups which continue to deceive the public, while I may have lost credibility among anti-smoking zealots, I certainly have not lost credibility in wider academic circles, including among the editors and reviewers of Epidemiologic Perspectives & Innovations, which chose to publish my recent paper.

It is really only within the tightly controlled and regulated circle of the tobacco control "academic" community that I have been blacklisted. Academics who are less fanatical and who have some regard for the rigors of science welcome a fellow academic who is willing to stand up against these powers and speak out for the truth.

Equally troubling is Stier's observation that due to these actions of the anti-smoking movement, we can no longer trust the public health establishment for scientifically accurate information.

This is precisely the problem. It is not the case that the majority of what anti-smoking groups are communicating is flawed. In fact, most of their communications are accurate. But once the public comes to believe that these groups are misrepresenting the science - even if the fallacious claims represent only a small proportion of those communications - the groups will lose their credibility entirely. None of what they say will be believed. Yet credibility is critical to the effectiveness of anti-smoking and all public health organizations.

As Jeff Stier writes: "Science eventually catches up with those who hyperbolize about risks, and the public learns to disregard them. It would be tragic to see some public-health advocates lose the mantle of sound science and end up going the way of the old Tobacco Institute."

Unfortunately, if things don't change quickly, I'm afraid that's exactly the direction the movement is headed. It may not become extinct like the Tobacco Institute, but it will lose its credibility, its reputation, and its effectiveness. How many more Wall Street Journal, Boston Globe, and Huffington Post articles does the movement need to see before it ends the character assassination and begins to actually address the scientific issues being raised therein?

Tuesday, November 13, 2007

Of note, the response fails to address the question at hand: is there or is there not evidence that a nonsmoker exposed to secondhand smoke for 30 minutes is at the same risk of a fatal heart attack as an active smoker?

Instead, the response addresses a statement that I have not taken issue with -- the assertion that brief exposure to secondhand smoke could potentially trigger a heart attack in someone with severe, pre-existing coronary artery stenosis.

Today, I am issuing what I consider to be the definitive challenge to TobaccoScam: Either provide the evidence to back up ASH's assertion that 30 minutes of secondhand smoke exposure increases the fatal heart attack risk of nonsmokers to the same level as active smokers, or else apologize to me for having improperly suggested that I am criticizing anti-smoking organizations for no valid reason.

In lieu of an apology, I would also settle for a simple acknowledgment that ASH's statement is inaccurate and misleading and should therefore be corrected.

Here is the specific statement that I have been criticizing, as it appears today on ASH's web site:

"Even for people without such respiratory conditions, breathing drifting tobacco smoke for even brief periods can be deadly. For example, the Centers for Disease Controls [CDC] has warned that breathing drifting tobacco smoke for as little as 30 minutes (less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker's risk of suffering a fatal heart attack to that of a smoker."I am challenging TobaccoScam, as well as other advocates and anti-smoking groups which have attacked me for criticizing what I believe are highly deceptive public communications, to provide evidence of each of the following:

1. Please document that the CDC has warned that 30 minutes of secondhand smoke exposure increases a nonsmoker's risk of suffering a fatal heart attack to the same level as that of active smokers.

2. Please provide the scientific evidence to back up the assertion that 30 minutes of secondhand smoke exposure increases a nonsmoker's risk of suffering a fatal heart attack to the same level as that of active smokers.

I will report back here on Thursday with any and all evidence that I receive from anti-smoking advocates or groups in support of ASH's public scientific claim.

The Rest of the Story

Now is the time to end the games that are being played. It is time, finally (after 2 years, I might add), to address the scientific substance of ASH's claim and to lay aside personal attacks and character assassinations. It is also time to stop diverting the issue by pretending that I am arguing something different than what I am.

I am not, and have never, challenged the notion that 30 minutes of secondhand smoke exposure could potentially trigger a heart attack in someone with severe coronary artery disease. For God sakes - eating a hamburger has been shown to cause similar changes in platelet activity and endothelial dysfunction as secondhand smoke - and could therefore be claimed to potentially trigger heart attacks.

That is simply not the issue at hand. The issue at hand is whether ASH's statement is valid or not.

Is there, or is there not, solid scientific evidence that a nonsmoker who is exposed to secondhand smoke for 30 minutes is at the same risk of a fatal heart attack as an active smoker? Yes or no?

If there is, then I need to apologize for making an invalid criticism of ASH's statement. (And I have to say that given the seriousness of my allegations, I am very interested in carefully considering any and all evidence that is presented to me. I simply will not continue to make these criticisms if there is evidence that I am wrong).

If there is not evidence that a nonsmoker who is exposed to secondhand smoke for 30 minutes is at the same risk of a fatal heart attack as an active smoker, then ASH is wildly deceiving the public and the scientific integrity of the tobacco control movement is in serious question. (And TobaccoScam owes me an apology).

In an email sent to thousands of tobacco control practitioners, the anti-smoking activist who defended inaccurate statements about the acute cardiovascular effects of secondhand smoke by arguing that people are too stupid to be told the actual truth has responded to my criticism of anti-smoking groups for making such inaccurate statements not by addressing the substance of the issue, but by issuing an ad hominem attack against me.

In the email, the activist writes: "My general approach to Mike Siegel has been to ignore him, since, according to him everyone but him is either corrupt or stupid. ... Siegel's continuing attacks on the science and organizations that are working to help the public understand the important, substantial, and immediate effects of secondhand smoke on the heart are following well-worn approaches that the tobacco industry pioneered: Put words in other people's mouths, set up straw men and knock them down. And, do it over and over and over again."

The Rest of the Story

It is becoming clear that the anti-smoking groups are unable to defend their misleading statements. In fact, their ability to defend these statements is so weak that the only approach remaining is to resort to the ad hominem attack.

When one sees an ad hominem attack, it is usually a clue that the person making use of this technique doesn't have a leg to stand on. Thus, the need to avoid the substance of the argument and resort to character attack.

The attempt to compare me with the tobacco industry is also a well-recognized aspect of the ad hominem attack. It is referred to as "guilt by association." The objective is to associate me with the tobacco industry and thus undermine my credibility: "Guilt by association can sometimes also be a type of ad hominem fallacy, if the argument attacks a person because of the similarity between the views of someone making an argument and other proponents of the argument."

Besides the invalidity of the ad hominem approach used by this anti-smoking activist, there are also some glaring factual inaccuracies.

First, I have never claimed not to be stupid. In fact, I readily admit that I am, in fact, quite stupid. Just last week in fact I searched for well over 30 minutes to find my car after work, only to remember just before calling the police to report my stolen car that I had taken public transportation to work that day.

I also spent close to two years trying to convince anti-smoking organizations to correct fallacious statements on their web sites. Quite a stupid waste of time that was - kind of like repeatedly banging my head against the wall.

So I readily admit my stupidity.

Second, I have never claimed not to be corrupt. I have repeatedly been accused of taking tobacco money to take the positions I espouse on this blog. Yet so far, I have failed to definitively deny those accusations. Maybe there is a good reason why I am critical of anti-smoking groups that lie to the public. Maybe that reason involves personal financial benefit.

So I actually refuse to deny that I am not corrupt, as well as stupid.

Finally, my readers will note that I have never put words in other people's mouths. Every one of my criticisms of statements made by anti-smoking groups has been accompanied by a quote of the actual statement made by that group. Thus, the validity of each and every statement I have criticized can readily be judged by any interested reader. Of course, those who simply choose to ignore this important issue are hardly interested parties. But they should be, since this issue has implications for the scientific integrity, credibility, and ethical standards of the anti-smoking movement.

One aspect of the statement, however, is correct. I do get all of my approaches directly from the tobacco industry. After following the anti-smoking playbook for 20 years, I've now switched over to the tobacco industry playbook. It's actually a little harder to follow now than the anti-smoking playbook is. Why? Because the tobacco industry playbook no longer calls for outright lies. It no longer calls for outright factual misrepresentations of the science. The anti-smoking playbook apparently does.

Thursday, November 08, 2007

In a startling turn of events, anti-smoking groups today and yesterday appeared to acknowledge that my commentary about the misleading nature of claims about the acute cardiovascular effects of secondhand smoke is scientifically correct and that these groups are knowingly deceiving the public.

In a one-two punch, the British magazine New Scientist and the Wall Street Journal have run articles highlighting the misrepresentation of the scientific facts by a large number of anti-smoking groups.

It all started yesterday with the release of an editorial and an article in New Scientist.

The editorial ("Don't mangle the facts, even in a good cause")argues that although the cause of protecting people from secondhand smoke may be a good one, it is inappropriate and unjustified to communicate "bad science" to the public in support of such policies, as many anti-smoking groups are doing.

According to the editorial, "it looks as if anti-smoking campaigners have been distorting the facts to make their case. Some have claimed that a non-smoker exposed to tobacco smoke for just half an hour can permanently increase their risk of heart attack. Yet a new study suggests that such statements are not supported by science. ... It would take years of repeated exposure for the effects to become potentially lethal. ..."

"Some might say, so what? If tobacco smoke is harmful, then surely anything that reduces people's exposure to it should be welcomed. Not so. Using bad science can never be justified, even in pursuit of noble causes. It only gives ammunition to those seeking to undermine your case. When anti-smoking groups want to make their point they should stick to the solid facts. There are plenty of them."

The editorial links to a news article which highlights my research demonstrating that many anti-smoking groups are misrepresenting the scientific evidence regarding the acute cardiovascular effects of secondhand smoke.

According to the article:

"California is fast becoming a smoker's nightmare. ... in Calabasas, smoking in public places, including the street, has been illegal for over a year. ... Anti-smoking campaigners argue that the scientific evidence supporting such measures is compelling. For example, Washington DC-based Action on Smoking and Health (ASH), which is frequently quoted in media debates on tobacco control, states in its promotional material that a single exposure to tobacco fumes lasting just 30 minutes can raise a 'non-smoker's risk of suffering a fatal heart attack to that of a smoker.' The British Heart Foundation (BHF) makes similar claims, saying that just 30 minutes of exposure can affect the cells lining the coronary arteries and 'contribute to narrowing the coronary arteries and reducing blood flow to the heart'".

"Can the risks of such a brief exposure really be that high? Not according to tobacco researcher Mike Siegel of Boston University, who examined statements made by nearly 30 anti-tobacco groups including ASH (US) and the BHF, as well as clinical studies upon which the statements were based. He believes the anti-tobacco groups distort the science to make their point. In doing so, he fears the campaigners could undermine public trust in what they say, and in the validity of powerful, legitimate evidence that links chronic passive smoking to heart and lung disease."

"Although a half-hour exposure does cause measurable changes in blood flow, the effects are only transitory and blood circulation returns to normal within hours, sometimes immediately, Siegel says. There is no evidence that a single exposure causes any meaningful damage in the way that the groups claim. 'It is certainly not correct to claim that a single 30-minute exposure to second-hand smoke causes hardening of the arteries, heart disease, heart attacks or strokes,' he says. 'The anti-smoking movement has gone overboard. The ban on streets is not scientifically justified.'"

The most interesting part of the article is the response from anti-smoking groups whose misleading claims I cited.

The article states: "Others feel that while there is no proof 30 minutes of passive smoking raises the risk of heart attack for a non-smoker it is not unreasonable to highlight the effect smoke has on the heart. 'When you take the science and put it in the public domain you can't include all the caveats,' says Stanton Glantz, a tobacco researcher at the University of California in San Francisco. The messages have to be simplified so people can understand them." ...

"John Banzhaf, executive director of ASH (US), says their statement was lifted from a report by the US Centers for Disease Control, and though he admits the risk to the heart is transitory, he does not believe you have to spell this out explicitly. 'It is such an obvious thing,' he says."

1."Others feel that while there is no proof 30 minutes of passive smoking raises the risk of heart attack for a non-smoker it is not unreasonable to highlight the effect smoke has on the heart. 'When you take the science and put it in the public domain you can't include all the caveats,' says Stanton Glantz, a tobacco researcher at the University of California in San Francisco. The messages have to be simplified so people can understand them."

Are you kidding me? People are too stupid to be able to understand that brief exposure to secondhand smoke has documented effects which could result in harm if repeated over many years? So instead, you have to just tell them that if you are exposed for 30 minutes, it could kill you?

You can't be serious.

Should we also tell the public that drinking three beers causes cirrhosis of the liver, liver cancer, hepatitis, and potentially, death? Is the public also too stupid to understand that while having 3 drinks is not going to kill you, if you have 3 drinks every day for many years, it could cause severe disease or death? Should public health practitioners therefore be putting out messages in which we remove all the "caveats" and state that drinking 3 beers puts you at the same risk of death as being a chronic, life-long alcoholic? And that drinking 3 beers may very well kill you?

Essentially, what this response is doing is acknowledging that the statements being made by anti-smoking groups are misleading and deceptive, but arguing that these groups have no choice but to be misleading and deceptive because the public is too stupid to understand the truth.

The people are too stupid to understand the truth, so we have to lie to them.

2. "John Banzhaf, executive director of ASH (US), says their statement was lifted from a report by the US Centers for Disease Control, and though he admits the risk to the heart is transitory, he does not believe you have to spell this out explicitly. 'It is such an obvious thing,' he says."

First of all, nowhere can I find any statement by the CDC that 30 minutes of secondhand smoke exposure raises the risk of a fatal heart attack of a nonsmoker to that of an active smoker. From what I can tell, that statement is simply erroneous.

But more importantly, what this anti-smoking group appears to be saying, in my view, is essentially: "We know that what we are saying is an absurd lie. But it is so absurd that we feel confident that people will not believe it. Thus, no damage will be done by our lie. It is so obvious that we are lying."

It is so obvious, in other words, that what the anti-smoking groups are claiming is such a bunch of garbage that the public will immediately see it for what it is and reject the claims.

If I were working for a tobacco company, I would be chomping at the bit. I could have a field day with this:

"We admit that smoking causes lung cancer, but there was nothing wrong with us claiming for years that smoking doesn't cause lung cancer. It is so obvious that what we were saying was absurd; no one in their right mind would have taken our statements on face value. Of course everyone knew what we were actually saying."

I guess the message here is that it's acceptable for anti-smoking groups to deceive the public as long as the deception is so great, and the claims so absurd, that no one in their right mind would believe those claims as stated. That way, no one will take the claim on face value and there is no need for the anti-smoking groups to defend the specific, stated scientific representations that they are making.

For me, this is truly a sentinel moment in tobacco control history. For the first time, anti-smoking groups have publicly acknowledged that they are, indeed, knowingly misrepresenting the science to the public.

They have defended their actions either by arguing that the public is too stupid to understand the actual truth or that the statements are so absurd that no one in their right mind would take them on face value.

Regardless, they have essentially acknowledged that the misrepresentation of science by perhaps hundreds of anti-smoking groups is intentional, and not just an innocent mistake.

Moreover, these groups have expressed absolutely no interest in correcting the mistakes and absolutely no interest in apologizing to the public for this deception.

This is disheartening to me. Because it means that at the end of the day, we have become no better than the tobacco companies themselves. In fact, right now, we may actually have sunk to a lower level than the current scientific claims that the industry is making. While they continue to become more accurate and forthcoming in their statements, we are heading in the opposite direction. We are becoming more and more deceptive, and less and less forthcoming and honest.

The saddest part of this is that we are apparently aware of what we are doing. We are defending it. We are not rejecting the assertion that what we are saying is inaccurate. These groups have readily acknowledged that they are making deceptive statements to the public. And they have the gall to publicly defend that deception?

The rest of the story is that it is now clear that anti-smoking groups are knowingly misleading the public in order to exaggerate the acute effects of secondhand smoke in an effort to promote widespread outdoor smoking bans.

It is clear that the truth is not enough to justify banning smoking everywhere outdoors. You can't convince policy makers that we need to ban smoking on every street and sidewalk if they believe that brief exposure to secondhand smoke does not cause disease. Misrepresenting the science is now being justified by the tobacco control movement.

Interestingly, while it is apparently acceptable for anti-smoking groups to misrepresent the science, it is intolerable and criminal for the tobacco companies to take even slight liberties with the use of language in their public communications. Of course, this double standard is justified because we're doing it all for the kids.

I have woken up today to a true nightmare -- the Wall Street Journal revealing that anti-smoking groups admit to knowingly deceiving the public in order to promote their policy goals.

While I always expected to read such revelations about the tobacco companies, I never expected to read the same thing about groups to which I have devoted years of my life in the service of providing sound scientific information to ensure that our communications to the public are honest, accurate, and dependable.

And to add insult to injury, the anti-smoking movement is now aware of this and they are defending it. There seems to be no hope that they will take note of the inappropriate actions and correct them in the future.

I never received a membership card when I joined the anti-smoking movement, but if I had, today is the day I'd be sending it back. These are not the ethical standards with which I would like to be associated.

About Me

Dr. Siegel is a Professor in the Department of Community Health Sciences, Boston University School of Public Health. He has 32 years of experience in the field of tobacco control. He previously spent two years working at the Office on Smoking and Health at CDC, where he conducted research on secondhand smoke and cigarette advertising. He has published nearly 70 papers related to tobacco. He testified in the landmark Engle lawsuit against the tobacco companies, which resulted in an unprecedented $145 billion verdict against the industry. He teaches social and behavioral sciences, mass communication and public health, and public health advocacy in the Masters of Public Health program.